Mohammed Chaudhury
20 Aug 2013 · Coroner Andrew Harris · London (Inner South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. pressure sores
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care on Murray Falconer ward in KCH between 27TM September and 9”
2. inadequate pressure sore prevention
“Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported since.”
3. insufficient nursing staffing
“Nursing rotas for the period were not available. Some days were reported as below establishment. (8 by day and 6 by night for 31 patients of which at least a % were high dependency). Not all bank shifts were filled.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity.”
Later report
“The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff.”
Responses
No published response was found on judiciary.uk.